<!DOCTYPE html>
<html>
	<head>
		<meta charset="UTF-8">
		<title>填写病历</title>
		<link type="text/css" rel="stylesheet" href="fontsawesome/css/font-awesome.css"/>
		<link type="text/css" rel="stylesheet" href="css/style.css"/>
		<link type="text/css" rel="stylesheet" href="css/datepicker.css"/>
	</head>
	<body>
		<div class="main_box">
			<h2><span></span>填写病历</h2>
			<div class="cont_box">
				<form action="#" method="post" id="user_form">
					<ul class="addpro_box adduser_box">
						<li>
							<label>就诊卡号：</label>
							<input type="text" placeholder="请输入就诊卡号" name="fullname" required data-rule-fullname="true" data-msg-required="就诊卡号不能为空"/>
						</li>
						<li>
							<label>姓名：</label>
							<input type="text" placeholder="请输入姓名" name="mobile" required data-rule-mobile="true" data-msg-required="姓名不能为空"/>
						</li>
						<li>
							<label>性别：</label>
							<ul class="pay_box clearfix">
								<li class="radio_box">
									<i class="fa fa-circle-thin fa-1x"></i>
									<input type="radio" name="payment" id="11" checked="checked"/>
									<span id="member">男</span>
								</li>
								<li class="radio_box">
									<i class="fa fa-circle-thin fa-1x"></i>
									<input type="radio" name="payment" id="22"/>
									<span>女</span>
								</li>
							</ul>
						</li>
						<li>
							<label>身份证号：</label>
							<input type="text" placeholder="请输入身份证号" name="mileage" required data-rule-mileage="true" data-msg-required="身份证号不能为空"/>
						</li>
						<li>
							<label>手机号：</label>
							<input type="text" placeholder="请输入手机号" name="mileage" required data-rule-mileage="true" data-msg-required="手机号不能为空"/>
						</li>
					</ul>
					<div class="probtn_box clearfix">
						<input type="submit" value="发放就诊卡" class="btn blue_btn"/>
					</div>
				</form>
			</div>
		</div>
		
	</body>
</html>